This is the end of the journey for many ANA soldiers. They arrive here after having stepped in the wrong place or having finally run out of luck at bullet dodging. For most of these young men — in truth, they are barely more than boys — their luck ran out in the last 10 days.

Many are missing limbs, others have been filled by shrapnel. Some have bullet wounds to the head, or other massive concussion trauma. The very fact that they are in ICU means that they are on the edge of death or — with a little help — on the edge of life.

The equipment that hums and beeps around them looks to be 10 to 15 years out of date. The blankets that cover them have a withered, white tinge. Despite some meticulous cleaning and sterilizing, the ward cannot escape its hard-worn, grimy feel.

A Canadian soldier in full body armour stands in the middle of the intensive care unit. He has a large green knife strapped to the front of his Kevlar vest and a sidearm on his right hip. His helmet is removed and strapped under one arm. On his head, he wears a cyan surgical cap and a surgical mask. For the moment his mask is pulled down under his chin. Security concerns are such that two additional Canadian soldiers armed with rifles stand as “guardian angels” at the back of the room.

Lieutenant Commander Vincent Trottier is part of the Canadian Medical Mission, assigned to help the Afghan National Army develop a training program that will help create the qualified medics, doctors surgeons and nurses of the future Afghanistan Army. Clumsily titled the Armed Forces Academy of Medical Science (AFAMS) Advisory Team it is made up of almost 40 Canadians, a smattering of Americans and a 10-strong Albanian contingent. It is overseen by Colonel Gisele Fontaine. They are based in Kabul but also have a team of 12 in Maser-e-Sharif in Northern Afghanistan.

“We are helping the Afghans deliver nursing, preventive medicine … and we are instituting a graduate medical program, and a dental program, along with an X-ray course,” said Col. Fontaine.

LCdr Troittier stands a good 8 inches taller than everyone else in the ICU. Around him, mass more than a dozen male and female ANA doctors and surgeons. They are all qualified in their own way to be here, but the Afghan system of doctoring leaves holes in their knowledge. Some arrive directly out of university into the ICU, having never touched a patient.

“In medical college, you learn theory, but you are not a doctor. You have to go through the residency program, learn how to do stuff and deal with patients, doing rotations on wards and clinics. They have not had that chance,” he said.

The quality of health care in Afghanistan remains among the poorest in the world, with a shocking ratio of fewer than 8 health care workers per 10,000 people.

Navy Captain Rebecca Patterson was the first on the ground to lead Canada’s medical training mission and she soon discovered the challenges, “As the minimal successes of the last seven years of one-on-one mentoring has demonstrated, no amount of mentoring will turn a poorly trained Afghan National Security Force (ANSF) healthcare provider into a capable and safe one who focuses of the needs of the patient.”

The task for the Canadian doctors and nurses who run the AFAMS program is to establish a quality, standardized, medical training and education system — one that will consistently produce qualified health professionals.

LCdr Trottier visits each patient, immediately asking questions of those around him. He offers no answers. To these budding doctors, he is offering a glimpse of his thought process. He is prompting them to figure out the questions that they themselves should be asking, helping them figure out what the answers might mean.

“They were not taught this way. You can go to classes and learn what pneumonia is, but unless you actually doing the work and trying to figure out what the signs, symptoms and clues are to get you to the diagnosis, you are not going to figure it out. But they are bright people. They just lack the skills and experience. And they have not been taught.”

This is LCdr Trottier’s third trip to Afghanistan. He previously worked as a surgeon giving clinical care and saving lives at Kandahar Air Field’s Role 3 hospital. Here, however, he is not supposed to intervene and this may well be the most challenging aspect for the healthcare professionals deployed on this mission. Providing medical care is the first instinct and at the core of Canada’s military medical professionals yet here they are asked to stand back and let the Afghans provide the direct clinical care.

One patient has been perforated by shrapnel and is in recovery after surgery to remove the various parts from his anatomy. The wound tracks on his X-rays show diagonal lines from low to high, left to right. His abdomen has been unzipped and zipped back up. There are dozens of smaller wounds across his body. He is secured to the bedframe by his arms and although unconscious is obviously desperately uncomfortable. He is running a temperature. LCdr Trottier asked the throng what they think is wrong with him.

A female doctor said, “He has tachycardia (heart palpitations).”

And LCdr Trottier points out that this is not a diagnosis, that instead it is a sign or a symptom that something is wrong. Simple – once you know. He hopes by teaching them to question what they see. it will lead them to correct answers and proper diagnosis.

“It is a multi-level problem. It is skills and knowledge, but it is also about structure, leadership, relationships and administration. It is about relationships between physicians. It is going to be a slow process. But things are getting a little better,” he said.

Dr. Majid Mojib is one of the group doctors gathered around LCdr Trottier and the patient. Dr. Mojib graduated from Kabul Medical University two years ago, and like many before him was dropped right into hospital work – right into ICU.

“In ICU, we don’t have any training program. No one has any specialty in ICU. We just learn from one another. We desperately need a specialty residency program for ICU. I hope that it is part of the Canadian plan,” He said.

The AFAMS program is busy creating nurses for the Afghan Security Forces. The program has already been running since 2008 and by the next graduation will have trained more than 100 nurses. Senior Nurse Advisor Commander Rose Collins heads the Canadian team.

“Before, they used to do a lot of theory but no hands-on, so you might have a graduating nurse who has never touched a patient. With this program, we actually have a skills lab, and we have clinical — so they are getting that hands on experience. And we are creating really amazing nurses,” she said.

Afghan combat medics take two months to train, but the new nursing program extends that course to a full year, greatly increasing the experience and knowledge of the graduates.

“We teach them more complex anatomy and physiology, they get more critical care and mental health support training and through knowledge for post-traumatic stress disorder (PTSD),” she said.

There is a hierarchical and insular culture to Afghan society, and that sometimes it gets in the way here. The ICU team often is handed patients without necessary care instructions from physicians and surgeons.

Lt. Col. Trottier is leaning over a patient and asking that the bandages be removed from his abdomen. None of the doctors here know what surgery was performed.

“You need good communication with your surgeon. You have to understand what was done in the abdomen, and what was done with the chest. Don’t be afraid. Ask, ‘Sir, can you explain to me what has been done?’ It is really important that you understand what [the surgeons] have done.”

The challenge before LCdr Trottier and the other members of the AFAMS program, including all of those who will rotate through on Canada’s supposedly final two unit rotations before the country marks its exit in 2014 is to create something now that will sustain the Afghans after the Canadians have gone.

LCdr Trottier said he believes the Afghans are grateful and that they understand the mission.

“I try to be as friendly as possible, and show them that I really care and I want to be helpful. I am leaving a wife and kids at home to come and teach them and support them. I hope that they are genuinely grateful. But I am really hoping that they figure out that time is on their side, and that things are going to get better, and that their lives are going to get better,” he said.

Of the nine very sick young men in the ICU during the rounds, one was deemed to be well enough to be moved onto the general ward. He is wheeled out while the doctors continue with their lesson.

“My role here is what my [Canadian military] mission is, but I am here ‘personally’ because I want to help.”

The same thing could be said of every member of Canada’s Medical contingent here in Afghanistan. They are not here for the money, or the prospects of promotion. They are here because they want to help.

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